Supporting Statement for 1240-0027 (CM-912) March 2010

SUPPORTING STATEMENT

Survivor's Form for Benefits (CM-912)

OMB No. 1240-0027

(Formerly 1215-0069)

A. Justification.

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.

This collection of information is required to administer the benefit payment provisions of the Black Lung Benefits Act for survivors of deceased miners. Completion of this form constitutes the application for benefits by survivors and assists in determining the survivor's entitlement to benefits. This form is authorized by the Black Lung Benefits Act (30 USC 901, et seq.) and by 20 CFR 410.221 and 20 CFR 725.304.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

Survivor applications are used by Division of Coal Mine Workers' Compensation (DCMWC) claims examiners to determine a survivor's eligibility for benefits. The claims examiners review the information submitted with the survivor's application along with any pertinent evidence already in file and, as necessary, informs the claimant of any additional information needed to meet the eligibility requirements to adjudicate the claim. The eligibility requirements are given in 20 CFR 725.212-225.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

The form is available for downloading at http://www.dol.gov/owcp/regs/compliance/cm-912.pdf. It can be filled out on-screen, printed, and mailed, or it may be printed, completed by hand, and mailed. It has not been made available for electronic submission previously because it contained a space for the signature of a witness if the claimant is unable to sign his or her name.  Electronic signature would have required two digital signature verification keys, a process unsupported by the Department of Labor’s software. However, virtually no forms with witness signatures are now submitted, and DCMWC intends to make the form fileable on-line within one year.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

There is no similar approved form used by DCMWC. Since the information collected is specific to Federal Black Lung beneficiary survivors, no other agency gathers this information.

5. If the collection information impacts small businesses or other small entities (Item 5 of OMB Form 83-1), describe any methods used to minimize burden.

Collection of this information does not involve small businesses or other small entities.

6 Describe the consequence of Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

This is a one-time collection from applicants; if the collection were less frequent, survivors eligible for benefits under the Black Lung Benefits Act would not be able to exercise their right to apply.

7. Explain any special circumstance that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentially that is not supported by authority established in statue or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can prove that it has instituted procedures to protect the information's confidentially to the extent permitted by law.

There are no special circumstances for conducting this information collection.

8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments.

Consultations with respondents take place at anytime a question or problem is raised.

A Federal Register Notice inviting public comment was published on March 12, 2010. No comments were received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

Respondents do not receive any gifts or payments to furnish the requested information.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.

Privacy Act System Notices (ESA-6 and ESA-30) provide confidentiality of information collected involving a claimant's claim file and automated record.

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

There are no questions of a sensitive nature on this form.

12. Provide estimates of the hour burden of the collection of information. The statement should:

Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices. Provide estimates of the hour burden of the collection of information. The statement should:

• Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

The burden estimate for the CM-912 is based upon the approximately 1,750 forms received yearly by DCMWC district offices. A survivor needs to fill out an application only once. It takes approximately 8 minutes per response, for a total annual burden of 233 hours.

(1,750 forms x 8 min= 14,000 min/60 = 233 hours)

13. Annual Costs to Respondents (capital/start-up & operation and maintenance).

The estimated total cost to respondents for the burden hours is approximately $1,062.00. The cost is computed by using the hourly Black Lung beneficiary benefit rate of $3.98. ($625 monthly x 12 = $7,500 a year/220 OPM annual workdays = $34.09/8 work hours a day = $4.26 hourly. $4.26 x 233 work hours = $993.00)

Operation and maintenance costs consist of mailing costs for the form. Approximately 300 of the forms are completed at Black Lung offices and thus incur no mailing costs. About 1,450 of the completed responses are mailed to the Black Lung offices at a cost of $.47 ($.44 postage and .03 for the envelope), for a total of $681.50. ($.47 x 1450 = $681.50)

14. Provide estimates of annualized cost to the Federal government.

The estimated total cost to the Federal government for this information collection is approximately $27,324.00. The cost is computed as follows:

a. Estimated printing cost: $300.00

b. Estimated mailing cost: $681.50

(stamps and envelopes @ $.47 for 1,450 forms sent to the claimant for completion, this excludes the approximate 300 forms completed by a Black Lung office)

c. Estimated processing cost: $14,319.00

(Claims Examiner, GS-12/5, spends about 15 minutes evaluating each form: $32.73 x 1,750/4 = $14,319.00)

d. Estimated SSA contract costs: $5,620.00

(SSA is under contract with DCMWC for claim taking services at SSA district offices throughout the country. The price per claim intake is $37.47. Of the 300 responses taken at DCMWC or SSA offices, it is estimated that approximately 150 will be taken by SSA. (150 x $37.47 = $5,620.00)

15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I.

There is a decrease in the approximate number of respondents from 2,000 to 1,750, due to the mortality rate of an aging claimant population. The total number of burden hours has decreased by 34 hours.

BURDEN HOURS RESPONSES

Current inventory 267 2,000

Requested 233 1,750

Difference -34 -250

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.

There are no plans to publish this collection of information.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

This ICR does not seek a waiver from the requirement to display the expiration date.

18. Explain each exception to the certification statement identified in Item "Certification for Paperwork Reduction Act Submissions," of OMB Form 83-I.

There are no exceptions to the certification statement.

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